Provider Demographics
NPI:1285094995
Name:SHEPHERD PARK MEDICAL CENTER
Entity type:Organization
Organization Name:SHEPHERD PARK MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMIRA
Authorized Official - Middle Name:RAZZAK
Authorized Official - Last Name:BADAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-882-5300
Mailing Address - Street 1:7733 ALASKA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-1421
Mailing Address - Country:US
Mailing Address - Phone:202-882-5300
Mailing Address - Fax:202-882-3758
Practice Address - Street 1:7733 ALASKA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1421
Practice Address - Country:US
Practice Address - Phone:202-882-5300
Practice Address - Fax:202-882-3758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD16145261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC024734400Medicaid
DCB94895Medicare UPIN